Healthcare Provider Details

I. General information

NPI: 1467413773
Provider Name (Legal Business Name): USAF 95MDOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 NIGHTINGALE RD BLDG 5513
EDWARDS AFB CA
93524-0001
US

IV. Provider business mailing address

4211 W 1ST ST UNIT #54
SANTA ANA CA
92703-4023
US

V. Phone/Fax

Practice location:
  • Phone: 661-277-2872
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number21258
License Number StateMA

VIII. Authorized Official

Name: DR. CHRISTIAN A PHAM
Title or Position: GENERAL DENTIST
Credential: DMD
Phone: 661-277-2872